I have recently taken a break from reading books for book reviews to attend to some of the books in my own “library of unread books”–you know, those books that in the past you had to have, but then never got around to reading, most of which are no longer quite as intriguing as they once were due to the “evolution of your interests” but which are still taking up space on your shelves. Those books. The first on my list, given our recent on-line discussions, but one for which my interests had not waned was The Philosophy of Medicine Reborn: a Pellegrino Reader, by Edmund Pellegrino. How ironic that I chose this book–and wrote a version of this piece–just prior to his apparently unexpected death.
Having barely begun the book, I already regret not having read it prior to some of my previous posts. In it, Dr. Pellegrino profoundly reflects on the meaning of the topics we have previously addressed–particularly the “ends” of medicine–yet with far greater clarity. He brilliantly grounds his philosophy of medicine, not in the physician or the profession, but in the unchanging clinical encounter between one who is ill and one who professes to be able to help. The telos of medicine therefore is the good of the patient where “good” is not a single entity merely encompassing the subjective needs and desires of the patient, but a quadripartite concept consisting of the complex interrelationship of the medical good, the good for the patient, the human good, and the spiritual good. The art of medicine, a concept that has been swept from our grasp in the tidal wave of the “science of medicine,” is the balancing of these four goods–“the fusion of the technically right with the morally good”–in the life of the vulnerable person who has presented for care.
By placing the clinical encounter at the core of medicine, Dr. Pellegrino distinguishes it from issues and concerns of public health, for at its core, medicine is this intimate clinical encounter, not the health of the community. Preserving that distinction in the days ahead will constitute a major challenge as bureaucratic powers increasingly conflate these two distinct entities, moving public health into the purview of the clinical encounter.
It is instructive to note that Dr Pellegrino lamented the fact that traditional professional ethics, derived from a self-imposed sense of professional responsibility had been damaged beyond rehabilitation or healing. Despite this recognition, he never evidenced discouragement or disillusionment over this loss but rather continued tirelessly to seek and promote an alternative ground for the ethics of the profession which he loved and to which he committed his life; hence, his selection of the clinical encounter for the grounds of his philosophy and ethic, for that, indeed, is the heart and soul of medicine.
I, for one, have not often shared his optimism or perseverance, and am continually tempted in my disillusionment to walk away from a profession that is no more–were it not for the clinical encounter–were it not for the relationship with the vulnerable persons who present for healing and care. Dr Pellegrino was the consummate philosopher-physician-educator, a man of integrity who lived and taught what he believed, teaching right up to the end of his life (apparently teaching a course for the Kennedy Institute in the week prior to his death at 92). While we lament his death and the void that his absence will leave in our profession, Dr. Pellegrino will live on as an inspiration for us all, not only in his writing and teaching, but in the example of his life as a physician, and as a man of authenticity and integrity. May he rest in joy and peace, knowing the vast legacy and immense treasure he has left behind–and in hearing those words, “well done, good and faithful servant.”